Dysmenorrhea

LI CS – Tutor 10
Cyclic Pain: Dysmenorrhea

• Dysmenorrhea is a common gynecologic disorder affecting as many as 60% of

menstruating women.
Primary menstrual pain without pelvic pathology

Secondary painful menses associated with underlying pathology

Primary dysmenorrhea usually appears within 1 to 2 years of menarche, when ovulatory

cycles are established. The disorder affects younger women but may persist into their 40s.
Secondary dysmenorrhea usually develops years after menarche and can occur with anovulatory cycles.
Primary Dysmenorrhea:

Etiology

The etiology of primary dysmenorrhea includes excessive or imbalanced amount of

prostanoids secreted from the endometrium during menstruation.
• The prostanoids resultin increased uterine contractions with a dysrhythmic pattern,
increased basal tone and increased active pressure. Uterine hypercontractility,
decreased uterine blood flow, and increased peripheral nerve hypersensitivity
contribute to pain.
• The decline of progesterone levels in the late luteal phase triggers lytic enzymatic
action, resulting in a release of phospholipids with the generation of arachidonic acid
and activation of the cyclo-oxygenase (COX) pathway

*Prostanoids are a subclass of eicosanoids consisting of the prostaglandins (mediators of inflammatory and 

anaphylactic reactions), the thromboxanes (mediators of vasoconstriction), and the prostacyclins (active in the
resolution phase of inflammation.)
Primary Dysmenorrhea:

Symptoms

The pain of primary dysmenorrhea usually begins a few hours before or

just after the onset of a menstrual period and may last 48 to 72 hours.

• The pain is similar to labor, with suprapubic cramping, and may be

accompanied by lumbosacral backache, pain radiating down the
anterior thigh, nausea, vomiting, diarrhea, and rarely syncopal episodes.

• The pain of dysmenorrhea is colicky in nature and, unlike abdominal

pain that is caused by chemical or infectious peritonitis, is relieved by
abdominal massage, counter-pressure, or movement of the body.
Primary Dysmenorrhea:

Signs

On examination:
• Vital signs are normal
• The suprapubic region may be tender to palpation
• Bowel sounds are normal, and there is no upper abdominal
tenderness and no abdominal rebound tenderness.
• Bimanual examination at the time of the dysmenorrheic episode
often reveals uterine tenderness; severe pain does not occur
with movement of the cervix or palpationof the adnexal
structures.
• The pelvic organs are normal in primary dysmenorrhea.
Primary Dysmenorrhea:

Diagnosis

• To diagnose primary dysmenorrhea, it is necessary to clinically rule out underlying pelvic

pathology and confirm the cyclic nature of the pain.

• During the pelvic examination, the size, shape, and mobility of the uterus; the size and
tenderness of adnexal structures; and the nodularity or fibrosis of uterosacral ligaments or
rectovaginal septum should be assessed.

• Pelvic ultrasound should be performed if symptoms do not resolve with NSAIDs. If no

abnormalities are found, a tentative diagnosis of primary dysmenorrhea can be established.
 Primary Dysmenorrhea:

Management

• Prostaglandin synthase inhibitors, also called nonsteroidal anti-inflammatory agents (NSAIDs), are effective for the
treatment of primary dysmenorrhea. The inhibitors should be taken up to 1 to 3 days before or, if menses are irregular, at
the first onset of even minimal pain or bleeding and then continuously every 6 to 8 hours to prevent reformation of
prostaglandin by-products. The medication should be taken for the first few days of menstrual flow.

• Hormonal contraceptives are indicated for primary dysmenorrhea unresponsive to NSAIDs or for patients with
primary dysmenorrhea who have no contraindications to hormonal contraceptive and who desire contraception.
Hormonal contraceptive agents (such as combined estrogen and progestin) or progesterone only oral contraceptives
(either cyclic or continuous regimens) etc. Hormonal contraceptives inhibit ovulation, decrease endometrial proliferation,
and create an endocrine milieu similar to the early proliferative phase of the menstrual cycle, when prostaglandin levels
are lowest. Decreased prostaglandin levels result in less uterine cramping.

• Nonpharmacologic pain management, in particular heat, acupuncture, or transcutaneous electricalnerve stimulation

(TENS), may be useful
Secondary Dysmenorrhea

Secondary dysmenorrhea is cyclic menstrual pain that occurs in association with underlying pelvic pathology.
The pain of secondary dysmenorrhea often begins 1 to 2 weeks before menstrual flow and persists until a few
days after the cessation of bleeding.

• The diagnosis of secondary dysmenorrhea may require review of a pain diary to confirm cyclicity and, in
addition to a transvaginal ultrasound examination, laparoscopy and/or hysteroscopy may be indicated.

• The most common cause of secondary dysmenorrhea is endometriosis, followed by adenomyosis and
nonhormonal intrauterine devices. NSAIDs and hormonal contraceptives are less likely to provide pain relief in
women with secondary dysmenorrhea than in those with primary dysmenorrhea.
Thank You